Post on 28-Jun-2020
Peripheral Arterial Disease (PAD) Outcome measurements
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Hirsch AT. Fam Pract Recertification. 2000;15(suppl):6-12.
Clinical Presentation PAD Patients
Critical ischemia
Acute Ischemia
Stabile
Claudication
Asymptomatic
PAD
3
30 34 38 50 55
CHF COPD
Average
Adult
Average
Well
Adult
Adapted from Ware JE. Ann Rev Pub Health. 1995;16:327-354.
Physical Component Score
SF-36 Physical Function Scores
36
Intermittent
Claudication
No. of
People
CLI
4
Greater risk cardiovascular events and death than amputation
Ouriel K. Lancet 2001; 358: 1257–64.
0
20
40
60
80
100
0 1 2 3 4 5 6 7 8 9 10
Time (years)
Pati
en
ts (
%)
Survival
Myocardial Infarction
Intervention
Amputation
Causes of death:
• 55% coronary artery disease
• 10% cerebrovascular disease
• 25% non-vascular
• < 10% other vascular
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Identify and treat systemic
atherosclerosis
Improve functional status and quality
of life
Preserve the limb
Prevent progression of atherosclerosis
PAD Therapeutic Goals
Treatment goals CI/PAD
Can we achieve these goals?
How do we measure them?
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Results of Critical Ischemia revascularization in EZ Tilburg (n 106)
Nonambulatory (n=18)
P<0.03
Limb salvage (days)
Ambulatory (n=38)
Ambulatory (n=38)
Nonambulatory (n=30)
P=0.00
Patient survival (days)
Inclusion jan 2001 - jan 2003
Flu et al. J Vasc Surg 2010 Feb;51(2):360-71.e1.
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Results of Critical Ischemia revascularization in EZ Tilburg (n 106)
Nonambulatory (n=18)
P<0.03
Ambulatory (n=38)
Ambulatory (n=38)
Nonambulatory (n=30)
P=0.00
Flu et al. J Vasc Surg 2010 Feb;51(2):360-71.e1.
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Results of PTA (dotter) versus exercise
Spronk S, Bosch JL, Veen HF, den Hoed PT, Hunink MG. Intermittent claudication: functional capacity and quality of life after exercise
training or percutaneous transluminal angioplasty--systematic review. Radiology. 2005 Jun;235(3):833-42. Epub 2005 Apr 28. Review.
Pilot Outcome of PAD ACHMEA
Pilot Hospitals Netherlands (3 UMC, 6 Teaching):
• Comparing outcome data PAD
• Case mix (comorbidity)
• Trying to improve performance
Claudication (PAD 2):
• Walking distance: Walking Impairment Questionnaire (WIQ)
• “Quality of Life”: VascuQol
Critical Limb Ischemia (CLI) (PAD 3/4):
• Outcome of bypass
• Limb salvage
• Death
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Positive aspects of this study
• Focus on outcome and quality of care
• Patient: centrally
• Goal: good outcome parameters on quality of care and
can be registered
• Central guidance of process
But there are some points of concern
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PROMS (patient recorded outcome measurements)
No one PROM was identified as a
'gold standard' for assessing HRQOL
in diabetes-related foot disease
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QoL versus Health Status (SF-36)
Health status:
evaluates health related limitations of
disease
Quality of Life:
Evalusates functional lmitations and relates
with personal perception of the patient on
sickness and treatment (social factors)
Hamming JF, De Vries J. Measuring quality of life. Br J Surg. 2007 Aug;94(8):923-4.
Breek JC, de Vries J, van Heck GL, van Berge Henegouwen DP, Hamming JF. Assessment of disease impact in patients with
intermittent claudication: discrepancy between health status and quality of life. J Vasc Surg. 2005 Mar;41(3):443-50.
And futher……
Reduced QoL not only depends on level of
claudication, but merely on dependence on
medication: comorbidity
Also other functional limiting factors and diseases are
important (arthrosis)
QoL in PAD
2006;141:161-61
High level of stress has negative impact on walking
performance, health status and QoL in PAD
2005;96:996-1001
Type D personality (“tobberts”) is associated with reduced QoL
on top of the effect of PAD with high level of stress.
And more…
What should happen?
There is no easy fix!!!!
What should happen?
Questionnaires:
• Patient centered
• Better, more simple
• Shorter and webbased
Shared goal setting:
• Structured intake
• Evaluation setting
• Goal checking
“Portrait” study: the new PAD registry?
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Patient centered Outcomes Related to Treatment practices in
Peripheral Arterial disease: an International Trajectory